I live in Colorado and I like to ski. When I began learning how to ski, I did so on very gentle green runs. This is true of almost all skiers and snowboarders. As a beginner, you learn on the easy stuff before attempting the more difficult stuff.
But a not-so-funny thing happens on the way to intubating a patient with a flexible endoscope. The clinician who is not familiar, not comfortable, not facile with the instrument doesn’t attempt to utilize it until he encounters a very difficult airway. Chances are he has already tried and failed with his difficult airway tool of choice—most commonly a video laryngoscope. With few options left, the patient deteriorating steadily and the situation rapidly becoming desperate, then and only then does the clinician attempt to intubate endoscopically. The anatomy is already difficult and multiple attempts to intubate laryngoscopically have traumatized the soft tissues of the pharynx. This clinician is much more likely to fail than he is to succeed. He probably is just a beginner at flexible endoscopic intubation. He has only attempted it a few times, if at all. He has made the critical mistake of trying to learn on a double-black diamond run. It is no wonder that many (most) clinicians will not bother attempting flexible endoscopic intubation in a difficult airway situation. This is simply wrong.
There is a debate within anesthesia circles as to whether or not the flexible endoscope should even be included in the next iteration of the ASA Difficult Airway Algorithm. If people have never used it, don’t know how to use it, aren’t any good at using it, should it even be an option in a difficult situation? To me the answer is obvious. The flexible endoscope is the most versatile, least invasive, least traumatic, safest intubation instrument that has been invented to date. It can be employed for nasal intubations, oral intubations, in patients of all ages, shapes and sizes, in any position. Nothing is gentler, kinder, safer or more universally applicable for routine, difficult and emergency airway management.
The key to getting good—really good—at flexible endoscopic intubation is to first learn how to do it on easy airways. And, just as in skiing, you need to learn the proper technique. The technique I have described elsewhere is extremely easy to learn and get good at very, very quickly. But you have to learn and practice on easy airways. This makes perfect sense. To try to learn on difficult airways makes no sense. And after you have gotten to the point where you feel you are quite good, you need to accumulate more and more experience until you can legitimately claim that you are a real expert at this skill. This skill is extinguishable, so you need to practice it regularly. There is a very good chance you will put your laryngoscope back in the drawer, where it belongs.